MAIL Application


Application  for NAMSMAP Membership
(See  Membership Options Below)

Mail  To:  NAMSMAP, PO Box 4459,  Helena, MT 59604.
and Submit application  fee.

(Print  this Mail-In Application, complete it and send  it with your check or money order to the address  above.  For electronic application and to pay by credit card, go to On-Line  Application)

NAME  ____________________________________  

AGENCY/COMPANY  NAME

_________________________________________

DAY  PHONE NUMBER  _______________________

FAX  NUMBER  _____________________________

E-MAIL  ADDRESS (PRINT CAREFULLY)

_________________________________________

MAILING  ADDRESS  _________________________

SHIPPING  (STREET NEEDED)

_________________________________________

CITY,  STATE, ZIP

_______________________,  ____, _____________

Resident  Insurance Producer’s License No.:

____________________
State:

_____________________
(Not needed if an Insurance Company Employee)

Membership  Option (Select One):
 
( )$210 Full On-Line,   ( )$125  Associate
**except Florida; Florida applicants please use “Full On-Line” only

I  understand that membership in NAMSMAP does not allow me to associate myself in any way with  Medicare, or any other government entity, nor am I allowed to hold myself out as a representative of such. I understand that, should I not satisfactorily complete both examinations within three months of the date of receipt of course materials, I will be allowed an additional thirty days in which to  satisfactorily complete both  examinations.
If I do not satisfactorily complete both examinations there will be a  $25.00 refund.

SIGNATURE  ____________________________ DATE  _______________


(For  electronic application and to pay by credit card,  go to
On-Line  Application.)

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Mail: NAMSMAP, P.O. Box 4459, Helena MT 59604 -- Phone: (406) 442-4016
© Copyright NAMSMAP, Helena, MT 2009-2019